If you read my newsletter, you are aware that the past two years have been a bit challenging for me in some respects. I have gone from being an avid long distance runner to now walking with a limp. My care up until recently was with one of the biggest integrated managed care consortiums in the United States. Unfortunately, in my case, working with them has been a disaster, and I am now shopping for a better way to treat my condition. However, that is not what this post is about. I am sharing it because my personal trials and tribulations treating a painful hip created the impetus for exploring a direr situation — a situation on which I believe my eclectic professional experience with UX and healthcare gives me a unique point of view.

There are pros and cons, strengthens and weak points, within any complex system — the healthcare system is no exception. When weak points are not looked at critically, that is when we can run into serious problems.

A National Emergency

In 2013, a group of scientists from the Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Stanford University and Mayo Foundation for Medical Education and Research provided hard evidence that something was not right with the opioid prescription rates in the United States. When they analyzed the prescription rates of opioid and non-opioid therapy for non-cancer pain in the period between 2000 and 2010, their data revealed some interesting trends. Although patients’ reports of pain remained unchanged in this period (pain was the main cause for one fifth of all visits to a doctor), opioid use nearly doubled (it went from 11.3 percent to 19.6 percent). Just as intriguing was their finding that the use of non-opioid pharmaceuticals did not follow the same trend. Only opioids were on the rise. Researchers struggled to find any association with patient, physician or practice characteristics that could explain the increase (Daubresse et al., 2013).

Leonard Paulozzi and his colleagues from the Centers for Disease Control and Prevention (CDC) cite even gloomier figures. They report that the sale of prescription opioid drugs keeps increasing; in fact, they quadrupled in the period between 1999 and 2010. In 2010, enough opioids were prescribed to medicate every adult American for a month (Paulozzi, Jones, Mack, & Rudd, 2011). To the best of my knowledge, this data has not improved in the past couple of years. The issue became so widely recognized that in 2014, a White House Summit was held to address the impact of opioids on American society (Clarke, Skoufalos, & Scranton, 2016), and just a couple weeks ago President Trump acknowledged that the opioid crisis is a national emergency.

Furthermore, the opioid epidemic has led to a significant increase in addictions, drug overdoses and deaths among Americans. To put this in perspective, the number of deaths from drug overdoses is now approaching the number of road deaths per annum. More people are dying of opioid poisoning than “street drugs,” drugs like cocaine and heroin (Paulozzi, Budnitz,& Xi, 2006). Many health experts are warning that this epidemic is worsening. The current state of affairs is having a grave impact on public health and safety, not to mention the financial burden it is putting on health insurance (estimated at $72.5 billion per year as reported by the National Drug Intelligence Centre).

Many health professionals offer strategies on how to better manage pain and minimize the risks of opioid overuse and misuse. However, we should not forget the fact that the number of patients experiencing pain has remained about the same over the past decade. Nonetheless, opioid prescriptions have been increasing. Why is that?

Hard Pill to Swallow: Is Patient-centered Design Part of the Problem?

I have built a reputation for my expertise on user experience and healthcare. A significant portion of my working hours is spent innovating ways to improve the satisfaction, engagement and fun end users have with digital health products and various fitness consumption modalities. While getting my Ph.D., I also did a lot of practicum work assisting physicians with employee burnout protocols (through an affiliation with a hospital group in the Bay Area; important to note, it is not the same group mentioned at the beginning of this post). During my work as a doctoral candidate on physician burnout, after malpractice lawsuits, the number one thing I heard that contributed to physician burnout was the cognitive burden a company called Press Ganey put on this particular physician group. If you are not familiar with Press Ganey, they are one of largest companies in the “patient satisfaction” business and their purported “mission” is to “support health care providers in understanding and improving the entire patient experience.” Simply put, they collect patient feedback data on doctors, and many times these assessments are tied to a physician’s livelihood.

More and more doctors and health experts have been recognizing that the increase in opioid use is correlating with the increasing emphasis on patient satisfaction. This might seem paradoxical at first (it did to me; after all, design thinking and great UX is about empathy and making the end user happy, right?), but it actually makes a lot of sense once you look at the facts at a macro level. Jenice Clark and Alexis Skoufalos of Thomas Jefferson University, Philadephia, and Dr. Richard Scranton of Pacira Pharmaceuticals conclude their article on the opioid epidemic in America with an insightful opinion from an expert panel:

It takes mere seconds for a primary care physician to write a prescription for an opiate; it takes 30 minutes to explain why he/she is unwilling to do so. (Clark, Skoufalos, & Scranton, 2016, p. S-7)

After digging further, I found patient satisfaction data now also gets reported via the HCAHPS survey. This is becoming a widely used healthcare quality metric. In fact, it is becoming the national standard for collecting the “patient experience” — so much so, scores from these surveys are starting to be incorporated into calculating reimbursements. In other words, in these cases, happy, drugged up patients indirectly mean more resources for a physician’s practice. Although patient satisfaction is a very subjective metric, it is used quantitatively to evaluate and compare physicians and determine financial compensation, job retention and promotions.

Are There Cases Where Grading UX Should Not Be Measured by the User?

Some experts warn that the “positive patient experience” is not necessarily linked to better health outcomes either. For example, in an article titled The Cost of Satisfaction, Joshua Fenton of University of California, Davis and his colleagues found that patient satisfaction was linked to:

higher admission rates,

greater overall expenditure,

higher prescription drug use and

increased mortality rates (Fenton, Jerant, Bertakis, & Franks, 2012).

Their nationally representative sample showed that satisfied patients did not necessarily fare better when compared to those that left their doctor’s office less satisfied. The rub: they are actually more likely to die!

Furthermore, studies show that patients often ask for services that are not clinically indicated. For instance, Kravitz et al. (2005) found that patients’ requests have a big effect on physicians prescribing antidepressants. Also, physicians whose patient rating affects their livelihood are more likely to budge and agree to patient requests (Pham et al., 2009). Patients expect their demands to be met. If unsatisfied, patients often now have a direct lever to affect a physician’s livelihood.

I Would Like the Credit, but I am Not the First to Stumble Upon This

Aleksandra Zgierska, Michael Miller and David Rabago of the University of Wisconsin-Madison, Madison (2012) believe that patient satisfaction surveys are generally a helpful initiative and can be a driver of positive change. However, they can also contribute to the prescription of addictive medications such as opioids.

When looking at these “patient satisfaction” instruments critically, you will often find the first question on the survey is an enquiry if you were satisfied with the way your doctor treated your pain. Since modern day primary care physicians experience time pressures, time-consuming discussions on alternatives to opioids are not necessarily promoted (for more on the burdens of modern healthcare, see my interview with Matthew Heineman about healthcare in America). When faced with high patient volumes and demands for interventions, it can be easier for doctors to simply write a prescription. In this way, the patient often leaves the (brief) office visit initially happy.

After working with burnt out physicians for several years now, I have an immense amount of empathy for this employee group. As such, it is very important to note that the harm here is not just to patients. As Zgierska, Miller and Rabago warn, these practices also can leave clinicians in emotional and moral distress. In fact, it is likely that the opioid epidemic is a silent yet significant factor in the explosion of cases of physician burnout. When you peel it back, it really is becoming a no-win situation for everyone.

When Great UX Gets in the Way of Great Outcomes

In my case, I likely need a hip replacement, but the integrated managed care consortium I was a part of does not like to perform replacements on people under 50 — especially males. Why? Although younger candidates have better surgical outcomes, this group (my strata) also has higher readmission outcomes. Having to get a second hip replacement is a more complex procedure and often has much graver outcomes than an initial replacement.

The most egregious aspect for me was that even though this consortium was impeding my effort to get better, the medical staff would still ask about my activity level during every office visit (by way of the worn out script of their rudimentary health risk assessment, affirming to me there was no real understanding of my condition). I’d have to inform them every time I was there because I would love to be more active. Instead of ever really developing a path forward, I’d routinely leave with a prescription for NSAIDs and/or opioids. It was more advantageous for them to keep their costs down and alleviate my symptoms than address the problem.

When I started to complain to other colleagues in healthcare, I quickly realized this is the elephant in the room. The over-prescribing of opioids is additionally concerning when many suggest that long-term use for chronic, non-malignant pain has more cons than pros. It brings many side effects, including gastrointestinal issues, confusion, respiratory problems and increased risk of infections and tumor growth (Clarke, Skoufalos, & Scranton, 2016). Inappropriate prescribing also means that more drugs become available to the general public through black markets, leading to further abuse and addictions. Ultimately, I have now stopped taking all prescribed painkillers and just suffer through the pain until I can treat the condition and not the symptoms. My current UX is terrible but at least I’m not a dope.

Do You Want Great UX, Or Do You Want Great Healthcare?

When it comes to improving the quality of care in our hospitals, I am not attempting to marginalize that pain assessment and pain management are two important standards. However, patient satisfaction — originally designed to promote quality of care — has in some cases undermined the principles of good medicine. This may sound contrarian from someone who generally advocates for patients to become the smartest person in the room about their particular condition, but maybe some decisions should be left to the people most qualified to make them. We need to foster systems that afford doctors the luxury of treating conditions and not simply addressing symptoms.

Instant gratification has its place, and it is natural to want to avoid discomfort. However, in this particular narrative, it is not a good replacement for legitimate treatment options. The current system is rigged to make you sicker. That has got to change, especially in cases like mine where there are better treatment options. Great UX is not always in the user’s best interest. In fact, as this post outlines, it can lead to many ill effects — on a personal, national and global level.

I hope your summer is off to a great start and you are finding your way to having tons of fun. I am starting to really enjoy further deconstructing the topic of fun. Seneca said, “we suffer more in imagination than in reality,” which is likely true. However, I believe we can make a case that we enjoy more contentment in imagination than in reality, too. So, if it is true that contentment is subjective (academics acknowledge this by measuring happiness through subjective well-being instruments), then a strong case can be made for the benefits of architecting a life through positional economics and taking measures to increase one’s prospects to engage in fun opportunities. In an attempt to practice what I preach, the family and I have made the decision to move from California to North Carolina — freeing up some resources for more life experience and (hopefully) more fun. Time will tell if we feel like the reward (opportunities for fun) outweighed the risk (loss of existing support systems).

More on that in future editions; for now, here are some more great interviews with two modern pioneers in digital health.

Business, Innovation and Entrepreneurship: This quarter, we look at the entrepreneurial side of digital health with Ryan Tarzy. Ryan is the current director of the Incubation Studio at CoverMyMeds. Before this position, he served as SVP of Business Development for PokitDok and has co-founded two companies, Medikeeper and Playful Bee. The interview with Ryan Tarzy about digital health can be found here.

Health and Wellness: This quarter’s health and wellness interview is with Daniel Freedman about virtual fitness. Daniel originally co-founded CyecureBox, a successful cyber security tool. He has since gone on to focus his efforts on the development of his new company BurnAlong — a virtual fitness startup that aims to help people find the time to exercise. The interview with Daniel Freedman about virtual fitness can be found here.

Life Experience: This quarter, I got to experience Lightning in a Bottle. It is an unbelievable festival with stunning art, good music, and lots of great educational sessions. I got to meet and learn from Dr. Jack Kreindler (@drjackUK) and Dr. Adam Gazzaley (@adamgazz) while partaking in some shenanigans with good friends and enjoying the scenic setting of California’s Central Coast.

Contribution: I was able to donate time, as well as money, this quarter. Through TECHquality, I helped improve the gender gap in digital health by mentoring a co-founder of the company Cleanopy. I also donated to former interviewee Jeff Atkinson’s son during his Tour de Pier effort, as well as donated a car to the East Bay SPCA.

It is the anniversary of my brother’s passing. Brian left a legacy through amazing memories with quality friends — a testament to the value of making time to enjoy and experience life. I believe he would be proud of the direction I have taken this endeavor and the directive to focus on fun for a while. His life is certainly a reminder to make the most of the time we have. My hope is to honor him by making sure I maximize people’s ability to have fun with the short time we have been given. The next edition will mark 10 years of this project. It has been quite a journey so far, and I look forward to it being a lot more fun as we continue on. I’m grateful that you are a part of it.

Daniel Freedman graduated from the London School of Economics (LSE). He started his career as a journalist and worked for several publications, including the Wall Street Journal and Forbes. He contributed to the bestseller “The Black Banners,” a book about Sept. 11 and the United States’ war with al-Qaeda that was published in 2012. Freedman later shifted his interest to the technology sector, working at tech startup Apploi and co-founding CyecureBox, a cyber security tool. After transitioning from Manhattan to Baltimore, he has been focusing on the development of BurnAlong, a startup that aims to help people find the time to exercise. During his eclectic career, Freedman has also held posts at the United Nations and the U.S. Senate.

1) What currently excites you about virtual fitness? How have things evolved from the days of Jane Fonda VHS tapes to the virtual fitness experience a user can consume today?

I think what’s really changed today is virtual fitness is allowing people to bridge the online and the offline fitness experience. New ways of delivering virtual fitness can finally bring people the “real” experience that they want, as opposed to having disconnected, lonely experiences with static content.

If you look at video games, the virtual world bridges that divide. If I go back to when I was a kid, if I wanted to play video games with a friend, I had to travel to their home. Today, my nieces can play with one another and/or their friends online, from their respective homes in different cities. They can see and speak to each other no matter where they are in the world. It’s the same in the business world where work tools like Skype and Google Hangouts have connected us.

What’s exciting to me in the fitness space is being able to bridge the divide and give everyone access to the experiences they want, when they want them. Fitness is about relationships, purpose and motivation. New advances in virtual fitness now allow us to do that at scale, with your workout buddies wherever they might be.

2) What are the limitations of delivering virtual fitness, and how have you seen this effectively mitigated?

If you go into any gym or studio, anywhere in the world, and ask, “Who is the most popular instructor here?” And then you ask them, “When was the last time someone said they can’t make a class, or was away for the summer, or traveling for work, and so could you film the class?” Odds are the instructor will say it was within the last two to three days. This reflects a massive lost opportunity for gyms and studios, because their members would prefer to choose a virtual experience with their favorite instructor, rather than strangers, if given that option.

BurnAlong does that, bridging that divide, giving people the connection to their favorite instructors/their friends, at a time and/or place convenient for them. And instructors can gain an insight into what people are doing outside of the gym, and help keep them on track.

3) Throughout the process of your product development, what has surprised you about virtual fitness delivery and consumption while building BurnAlong?

One big surprise is the willingness of people to try something different from home, or get started on their fitness journey. We see with companies, that often people have heard about top local instructors, they’re very curious to try them out, they’ve just never had the time, or confidence, or motivation, to actually take the class. But being able to experience it at home, from the comfort of their own home, makes a big difference.

We see this especially with companies and their employees. Right now, for many, five percent of employees participate in wellness programming. What we’ve found is that it’s not that the other 95 percent of the company isn’t interested. On the contrary, there are just a lot of barriers to attend (e.g. schedule, family commitments, aversion to working out with co-workers in an open setting, etc.). We found that virtual fitness is great for those who do not like exercising in front of others (especially colleagues and/or strangers).

For instance, yoga can be intimidating if you do not understand it. Virtual fitness allows someone who wants to be a little more confident before they subject themselves to other peers seeing them engage in activity [to get some practice]. They can get accustomed to movements, gain familiarity before engaging in the activity in a group setting.

For an instructor, this can be quite eye opening. Big personalities can be intimidating. Virtual fitness allows participants to understand the instructor, the class, they get to know the routines — a relationship is built before having to step in an unfamiliar setting. Through this process, a user can take steps to understand group dynamics before leaning in.

Virtual fitness is a great way to onboard new entrants into fitness who would have been too intimidated to ever get started otherwise.

4) Exergaming is a facet of virtual fitness that has had a lot of press but seemingly always falls flat after the initial hype (i.e. Wii Fit, Pokemon Go, etc.). Why do you think gamification has ultimately not lived up to the hype, and do you see this changing in the future?

Anything can get boring, unless it’s changed up. It’s the same limitation of the old way of delivering virtual fitness — where you’ve only got the same 10 options and the expectation is you are meant to keep going through that same 10 classes over and over again. Most people who buy fitness DVDs don’t buy only one; these folks have got piles of them. They want choice and variety. If there were only 10 books that everyone wanted to read, there wouldn’t be a need for Amazon, right? So too for fitness, there’s not just 10 ways of working out; the rise of boutiques reflects the desire for so many different people to work out in so many different ways.

The appeal of attending fitness classes in person with friends is that while the workout may be similar, the instructor will change things up, and your friends will chat about different things. The conversation is going to be different every week. What virtual fitness can now do is bring that variety to you in your home, with your friends, with fresh content from instructors, when you can’t make it in-person.

5) How do you see fitness evolving over the next five to ten years? How will virtual fitness change the way people currently consume fitness?

What we believe in at BurnAlong, and what our product is based on, is that people increasingly want unique experiences. I think virtual fitness has got the power of bringing fitness to people wherever they are — that specific type of experience that they want whenever and wherever they want it. We believe the virtual compliments the in-person experience, rather than replacing it (which most online companies believe).

The virtual can also bring special classes to places where previously people didn’t have that experience. People talk to friends across the country and all over the world about their favorite instructors; now those friends can experience those classes with that friend. Geography no longer needs to be a limitation.

In five years, I might wake up planning to attend my favorite cardio class at eight o’clock in the morning, but I wake up and Amazon’s Alexa or Google Home or another connected device will say to me, “Daniel, your noon meeting has just been moved, and you do not have time to physically attend your eight o’clock class. However, I’ve notified your instructor that you’re going to be joining online rather than in person.”

My co-worker Harry who takes the class with me is in London for work, and will be taking the same class virtually since it is his favorite, too. We choose to take the class live together. I log in at eight o’clock, wave to Harry and the instructor, who sees me and says, “Thanks for joining Daniel. Sorry you couldn’t come in person. You know I see your heart rate is already at 140, good run earlier … Daniel, you are already ready to go!”

It’s an experience where, just because you cannot do something in person, you are no longer limited. The virtual world bridges that divide, makes people more efficient, and allows them to use their time more effectively without sacrificing quality. This will only continue to improve in the years ahead

You should never be in a situation where just because you are traveling this week, or just because you can’t get a babysitter, or just because you had to work late … you can’t get the type of fitness experience and expert guidance you value and deserve.

Ryan Tarzy received his B.A. in Economics and Applied Mathematics from Northwestern University. Early in his career, he realized that his talents involved combining the role of an entrepreneur with that of an advisor. Since then, Ryan has been passionately working on moving healthcare forward and has founded or led several digital health startups. In 2003, he co-founded MediKeeper, one of the earliest digital health startups. He later served as CEO of Personal Health Labs, a lab focused on R&D in areas such as health gaming and interoperability. He now serves as Director of the Incubation Studio at CoverMyMeds. Prior to CoverMyMeds, he served as Co-Founder of Playful Bee and SVP of Business Development for PokitDok. He has recently begun to angel invest in digital health startups.

1) Many have attributed the impressive evolution and expansion of digital health to a move towards human-centered design, suggesting that a lot of previous health technology was engineered in a such a way that user experience was an afterthought. In your opinion, to be a success in digital health is user experience more important than utility? And why?

I think it is absolutely accurate that in the past, user-centered design has arguably been an afterthought. However, as we evolve into this next wave of digital health beyond Health 2.0, I think it is unfortunately still true that neither utility nor user-centered design is the most important factor of success. I would say at this point, success relies primarily on a solid business model. You can have fantastic user-centered design, you can have some utility, but if you have not figured out the way you’re going to get reimbursed, the way you’re going to get paid, or have a compelling value proposition for the direct consumer, then you are still going to struggle to be successful in digital health.

That said, I do believe user-centered design is driving some really exciting things coming out of the new wave of companies in digital health. I’m really encouraged by that, and I hope that it continues. I think that it does become a differentiating factor when you compare multiple companies, all of which have the reimbursement model and/or revenue model figured out.

2) As an investor in digital health startups, what do you look for in early stage companies trying to make it in health tech? And, what is a common flaw of new entrants that you feel could be easily avoided?

First and foremost, I look at the founders. Founders, to me, are the No. 1 determinant for success. I look for founders that, if they haven’t done this before, have deep domain expertise. They have dealt with the business problem before, they understand it, and they’re now trying to solve it through their own company.

I also look for founders that have a combination of passion and hustle that makes me confident that they’re going to be able to get past the inevitable roadblocks and hiccups that are going to take place when you’re trying to tackle an industry like health care. Those are the top two things I look for.

Lastly, I look for companies that I feel like I can provide an unfair advantage (while advising them). I want to feel like I can bring a lot more to the table than just monetary value as an investor.

In terms of things that I think are common mistakes … ultimately the sales cycles in health care are just really long. What I see is most new entrants will come in vastly underestimating the sale cycle and struggle. When you have these long sales cycles, what kills you is waiting on those maybes. You really have to aggressively develop process to manage the pipeline and be able to move beyond that first LOI, or unpaid pilot, and get yourself more quickly to a proven revenue model — a robust pipeline that is bringing in recurring revenue.

Another common mistake is a great idea, with a lack of domain expertise. It sounds self-serving as a healthcare investor with deep domain expertise to say this, but it is always good to have someone with healthcare expertise as an investor and/or advisor in the group. You need an advisor with specific knowledge in the area that you’re trying to tackle.

For example, a lot of people lump life science investors in with health IT and digital health investors — these are completely different businesses. One is dealing with long development cycles and a completely different type of regulation. The other is more about reimbursement cycles and enterprise sales and understanding the intricate players in the space. They are just different animals. You need someone, depending on which area you’re tackling, with that specific type of healthcare domain expertise. Very few can do both.

This is very personal to me because the first company I co-founded was one of the early personal health record companies. My co-founders and I built the company on the premise that there is this need, this obvious need, for a more central place for individuals to manage their health information. Back then we called it personal health records (PHRs), now you might call it a health portal. It just still feels like something that should exist but, I agree, at this point there has not been a huge success in this space yet.

What’s really interesting about this is there’s information leaking out that both Google and Apple are now attacking this space with new technologies. The ubiquity of smartphones, or even now through smartwatches, might potentially be a new opportunity for this to take hold.

I’ve always believed that the ideal health information exchange is the “HIE of One,” where the individual is the conduit of their own health information. The panacea of interoperability to create a universal portal, whether it’s Google Health or Microsoft HealthVault, is the wrong way to think about it. We need the ability for an individual to easily be able to take control of their health information and have control of the back and forth. Then, consume their data in whatever portal they want. I hope this is where things are going and I’m excited to see Apple coming into the market and Google seemingly retrying to attack this market. I’m really intrigued to see what they come up with.

4) What is your take on the longevity of today’s wearables? There are numerous articles with click-bait titles indicating the smartphone is dead within five years. One could argue that might be the same fate for most wearables today. Where do you see the puck heading for wearables?

I feel like five years is too aggressive to say the smartphone will die, but I may be wrong. I think that I’m much more pessimistic about the future of wearables as they exist today. We are seeing the early stages of these devices; they have passionate followers; they literally have millions of users out there. If you believe that wearables are going to become a more ubiquitous thing — I will say today’s wearables will likely be starkly different five years from now. Looks at Apple’s AirPods, those will change the smartphone and are technically a wearable. Wearables will evolve in ways we cannot predict.

It comes down to, what do you define as a wearable? Staying with the AirPods example, this is a sign that we’ll be utilizing voice for data entry … speech will be integrated into our car, which is integrated into our watch and into our AirPods. And really, the cloud becomes more and more the world we live in versus having our nose in our smartphone.

So although I am pessimistic that devices like the Fitbit will have legs five years from now, I am optimist about the future of computing being more integrated into all parts of our life in a, hopefully, more user-centric way without having to have our nose buried in our smartphone all the time. As voice gets more and more compelling, we will not need to physical interact with devices, limiting the need to “wear” anything.

5) In your opinion, what are two underrated and/or little-known companies right now in digital health that you believe are positioned to make a huge impact (in the future) and why?

1) LeapCure: This is a company that has really cracked the code on recruiting patients for clinical trials. It is fascinating to me that over 60 percent of clinical trials fail due to patient recruitment issues. That’s just staggering to me and just seems like such a big problem that we haven’t been able to crack.

This company has been able to use techniques that have been utilized in other non-health care markets to micro-target individuals — even for very rare diseases. One of their customers specifically specializes in rare diseases for children. So, truly the needle in the haystack kind of problem: how do you find the less than 20 patients in the country that would qualify for this clinic trial?

They are able to do that, and will likely make a huge impact. They are reducing the cost of patient recruitment and increasing the success rate of clinical trials. That could have a far-reaching impact on the industry. So, I’m really bullish on that and what they’re doing and excited to work with their team as an investor and board observer.

2) Paubox: Sometimes seemingly boring companies on the surface are in the best position to make an impact. Paubox operates in the area of email and disaster recovery. Sounds incredibly boring for healthcare but, what they’ve done is, they have cracked the code of how to deliver HIPAA-secure email — and they do that in a way that is user-friendly. You can finally simply use your Gmail account as a doctor, and they’re able to make that HIPAA secure for communication with patients. All the friction created by email alerts that push you to a portal, only to hassle with additional passwords and clunky communication channels. Paubox solves all that. Finally, you can simply email your doctor … like you email the rest of the world.

What is Fun? The Oxford English Dictionary (O.E.D) defines fun as “amusement, especially lively or playful.” As an adjective, the word is described as “amusing, entertaining, enjoyable.” “For fun” or “for the fun of it” means “not for a serious purpose.”

The standard definition of fun suggests some overlap with the concept of play. In fact, these two words are often mentioned together (e.g. fun and games). However, play often appears to be the overarching term, where fun is more specific to experiencing enjoyment. For example, when defining play, play researcher Scott Eberle, Ph.D., writes that fun is one of the basic elements of play. He also observes that we play because the act of play promises fun. If there were no fun in play, we would likely not play (Eberle, 2014). This suggests a relationship between the concepts of fun and play, a possible causality perhaps: fun is a natural byproduct of play — fun is intrinsic to play. Eberle also argues that although there are many ways to develop knowledge, self-assurance and vigor, none of them are as fun as play.

Another academic concept that is used when discussing fun is “flow.” When Gayle Privette of the University of West Florida attempted to distinguish between peak experience, peak performance and flow, she defined peak experience as mystic and transpersonal, peak performance as transactive and flow as having fun (Privette, 1983).

Casual and Academic References to Fun

Definitions of fun are generally discussed as a result of an act and/or engaging in activity. Some authors focus on the fun side of things/activities and talk about the hedonic aspects of certain activities. As such, in academic writing, fun is often equated with hedonism. For instance, Barry Babin, William Darden, and Mitch Griffin (1994) took the hedonistic value of shopping (e.g. shopping for fun) and contrasted it with shopping’s utilitarian value, which is more concerned with usefulness and task completion. Utilitarian shopping can almost be regarded as work. Shopping for fun, on the other hand, is personal, subjective to the shopper and often entails playfulness. The participant values the experience itself because the endeavor is entertaining. In short, many activities can be analyzed for their ability to induce fun — emphasizing entertainment and enjoyment of the process rather than its practical value.

When activity is done for fun, it often involves increased arousal, perceived freedom, fantasy fulfillment and escapism (Hirscham, 1983). The saying “time flies when you’re having fun” indicates that the concept is also connected with our perceptions of temporality and can influence the subjective component of time. This popular anecdote is a cultural artifact that further alludes that flow and fun are related social constructs.

People sometimes also talk about “short-term fun” and contrast it with “long-term gains,” suggesting that fun could obliterate the lasting success of an individual. Fun and play often get negative press, especially when adults engage in fun activities excessively. It sometimes gets implied that people’s efficiency and productivity could decline if they overtly prioritized fun. Modern research, however, does not support that negative proposition of fun (e.g. R. Fluegge-Woolf, 2014).

Can Fun Be Universally Defined?

Although fun is often connected with play, few would argue play is the only time we have fun. For instance, for many, work can be fun as well. A task like gardening can be perceived as monotonous to one person while being perceived as fun by another. But, does work cease to be work if we have fun? Actually, fun in the workplace is increasingly being researched. Researchers are exploring strategies that help make our work lives more fun. For instance, there are evolving applications of gamification. Gamifying work involves creating strategic tactics in an attempt to make arduous tasks more fun. New studies have confirmed that a fun work environment creates more productive and creative employees, therefore showing that both parts of the “work hard, play hard” phrase can actually coexist (R. Fluegge-Woolf, 2014).

Your perception of whether something is fun depends on your mindset, ability and skills, the environment as well as those around you (your relationships). For example, taking public transportation can be a tedious, mind-numbing activity. If you’re headed to a concert with a group of friends, though, it can be the ride of a lifetime: spending time together, chatting while excitedly anticipating the show — in laymen terms, “a ton of fun.”

What is clear is that fun is a subjective construct. What seems fun to one person might be perceived differently by somebody else. Therefore, perhaps the most relevant question is: How do you define fun? What is fun to you?

OK, to all you non-parents out there … I am going to go out on a limb here and share a secret held by us on the other side — misery loves company, so when one of us tells you, “My children are the best thing that has ever happened to me,” or some similar thinly veiled ploy to have you come join us in Suckville — don’t you believe it! The reality is we likely miss you dearly, yet there is no reasonable escape from the trap of our new reality, and our only hope is to trick you to come along. Like someone drowning — clinging on for dear life — we are ready to take you down with us. Therefore, it should be no surprise that a recent study out of the Indiana University—Purdue University Indianapolis by Leslie Ashburn-Nardo suggests child-free adults consistently face moral outrage by their childbearing counterparts. The hard truth is, many of us dream about our prior lives sans kids. Often kids aren’t fun and many of us long for pieces from our previous autonomous lives.

Joking aside, I love my kids. There are moments when it is really fun being a parent. My kids bring me occasional joy; they most certainly give my life a sense of meaning and purpose that was not there before. Like many other parents, I do my best to juggle priorities and sacrifice my own needs for theirs. Being a psychology geek, I truly enjoy watching them develop and thrive. Parenthood gives me a sense of accomplishment; there is no question I love my kids. Surely, I must be happier with two little bundles of joy in my life. Right? Right?!?

The Parenting Happiness Gap

Not according to science; research studies from different parts of the developed world have been suggesting for some time now that people with kids are less happy than their non-parent counterparts. So if you have been struggling with the self-actualization that your new life parenting is not as fun as you thought it would be … don’t stress, you are in good company. Those who have read Dan Gilbert’s Stumbling on Happiness or All Joy and No Fun by Jennifer Senior are probably already familiar with some of the previous science. Important to note, this does not mean that parents are (necessarily) unhappy. It just verifies that there is a happiness gap between the two groups. To put it more bluntly, when your ex-drinking buddy tells you, “My kids make me so happy,” they’re probably full of shit. This is especially true here in the United States. More than other countries in the world, there appears to be a strong link between parenthood and lower emotional well-being in the United States.

I’m not trying to be a polemicist. As I previously suggested, there is an abundance of research to support this claim (see Glass, Simon, & Andersson, 2016 for a comprehensive list of studies). For example, research published in 2005 in the Journal of Health and Social Behavior suggests that having children is associated with decreased mental health. This work also suggests parents reporting significantly higher levels of depression than their childfree counterparts.

There is a gender bias to these statistics due to hormonal issues associated with postpartum phenomena. However, these effects are observed in both men and women (Evenson & Simon, 2005). Cohabiting with dependent children is a period of parenthood that has been associated with the highest degree of stress levels (this goes for both genders); of this group, parents with minor children are the ones who usually experience the highest time and energy demands (Evenson & Simon, 2005).

“Don’t Worry, it Gets Better” Might Be a Lie, Too

According to Ranae Evenson of Vanderbilt University and Robin Simon of Florida State University, even empty-nesters have trouble reaching the levels of happiness experienced by non-parents. This is unfortunate interesting since many people believe that once their children are all grown, parenthood is more enjoyable. A meta-analytic review published in the Journal of Marriage and Family suggests that, after having children, couples actually report being less satisfied with their marital relationship compared with non-parents (Twenge, Campbell, & Foster, 2003). Twenge, Campbell and Foster conclude that lower marital satisfaction might be due to new role conflicts from the change in family dynamics, as well as the increased autonomy that comes with the empty nest. In other words, you wake up from Suckville and realize you still want to go to Burning Man, only to discover your partner would now rather watch “The Good Wife” reruns.

In a nutshell, science shows us (once again) what we already know but for some reason decided to kid ourselves about: being a parent is hard fucking work. While fantasizing about the birth of a child, we usually look forward to personal gratification, meaning and purpose, but these positive emotions are fleeting and ultimately get eclipsed by the vast variety of stressors associated with childcare. These underestimated stressors can often lead to a poorer sense of well-being (Umberson & Gove, 1998).

United States + Kids = Suck

From all over the globe, those who romanticize parenthood still acknowledge the stressors connected with parenting, but it seems like parenting is especially hard here in the United States. I have dug into the research, and stress theory has failed to explain why American parents feel worse than their counterparts in other countries (Glass, Simon, & Andersson, 2016). Many experts agree that the reason American parents report less happiness than parents in other countries is a lack of parenting support (when compared to collectivist cultures) and the lack of support offered by governmental programs (e.g. family leave, significant tax breaks, etc.). While in some developed countries, childbearing brings a number of social and financial benefits — well, let’s face it, the United States simply fails miserably here.

A group of researchers looked into resources provided to parents in different countries and examined whether the happiness gap between parents and non-parents was smaller in countries that provided more family assistance. They confirmed that the (distal) source of parenting stress generally originated in the respective countries’ social, economic and policy constraints. They referred to this as the macro-level cause for parental negative emotions. Their analysis showed that out of 22 OECD countries, the greatest happiness gap between parents and non-parents was experienced in the United States.

In fact, us American parents report being 12 percent less happy than those without children. In contrast, countries that provided more resources and social support for parents (paid work leave, work flexibility, subsidized childcare) generally had a smaller disparity in happiness between parents and non-parents. Truth be told, in some countries (e.g. Spain, Portugal, Sweden and Russia), parents actually reported being as happy (even slightly happier sometimes) as their non-parent counterparts (Glass, Simon, & Andersson, 2016).

Modern Family

Another factor is parenting does not have the social value and esteem attached to it that it did 50 years ago. We can now decide for ourselves when to have children. That is why some social scientists argue that when we compare people with children to non-parents, we are in fact comparing two groups of people who made different choices and have different attributes and preferences. Admittedly, the science here is as messy. It might, therefore, be more relevant to compare people’s happiness before and after they have had kids.

Professor Andrew Clark of the Paris School of Economics and his team are currently working on the book The Origins of Happiness, which is looking at the determinants of well-being in four countries: the United States, Germany, Australia and the U.K. They presented some of their findings at the Wellbeing Conference 2016 which was held last December and was organized by the OECD and the London School of Economics (LSE). After four years of following new parents, their preliminary findings reaffirm that parenthood does not improve subjective well-being in the long run. The positive effects only last for the first 12 months after the baby is born. Unfortunately, after that, the well-being score of parents starts to decline.

Is Being a Happy Parent Possible?

OK, so parenting can suck … but here we are … and we love our kids … so WTF should we do? The good news is parenthood does offer many opportunities for some of the most worthwhile moments of your life. We lose a lot of autonomy as parents, but we can choose to bring more joy into our lives through our children. A study led by Katherine Nelson, a psychologist from the University of California, Riverside, shows us again what we already intuitively know — that the relationship between parenthood and well-being is very complex. It is influenced by so many factors, including: parenting style, emotional bonds between the parents, the child’s temperament and age…

When evaluating parental happiness, we should look at the whole context; it is important to observe why and how we, as parents, become more or less happy. If we have “bought in,” we can experience positive emotions through our enhanced social roles (Nelson, Kushlev, & Lyubomirsky, 2014).

Moreover, to counter the somewhat negative research on parenthood, Nelson and her colleagues demonstrated (in three studies) that parents (especially fathers — go dads!) can be happier and experience more meaning in life compared to non-parents (Nelson, Kushlev, English, Dunn & Lyubomirsky, 2013). So, being a happy parent is in the cards, if you are ready to work.

Let’s explore how:

Allow Time for Unstructured Play

Play is a source of happiness for kids, as well as adults. It is baffling to me that kids seem like they’re continually being deprived of free play. We’ve become too dystopian. Some of the silliest fights I have with my wife are about my kids going outside because they might get dirty. “Yeah, no shit, that is part of the fun of going outside.”

Statistics show American children (as well as children in other developed nations) have less and less free time to engage in free play activities. Our kids’ lives are increasingly highly structured and controlled. There are reasons for this, sure, but I want you to think about some of your favorite childhood memories for a moment … they probably involve at least some images of unstructured play, shenanigans with friends, moments of a carefree existence … moments when you were not directed, because you were a kid!

How does this make me happier? If we are always helicoptering over our kids (more on that later), we have less autonomy. Autonomy makes us happy. Furthermore, Professor Peter Gray argues that the decline of free play importantly contributes to an increase in different psychopathologies among young people, including: anxiety, depression, narcissism and difficulty focusing (Gray, 2011). In his writing, Gray (2014) suggests that children need to be allowed time to play freely, with other children, and away from adults. So when we eliminate the autonomy out of our lives, and the lives of our children, we create a perpetual death spiral. It is a bitter pill to swallow, but your parenting style might be part of the problem.

We need to give children some space to express their personality, learn, develop their skills and build social interactions. In his book, Free to Learn, Gray further explores these concepts and looks for ways to improve children’s happiness and the potential to learn.

The first rule of being happy (and raising a happy person) appears to be giving your kid some space. Let them play freely and get absorbed in some self-directed activity that has not been organized for them. It is good to have fun with your kids, but if one or both of you are not having fun anymore, it is counterproductive. Letting your kid free play also helps you recharge and have more fun during the time you do share experiences.

Don’t Make Play Your Duty

When you do play with your kids, avoid engaging in it as a sense of obligation. Play should be fun for everyone involved. Otherwise, it is not play. Hey … I get it, singing “Frozen” karaoke for the nth time isn’t your idea of fun.

Our interests, energy, humor are different than our children … you don’t need a Ph.D. behind your name to observe that. This makes it difficult to bridge the age gap in parent-child play, but you can get creative if you try. Gray (2014) suggests finding ways that fit the abilities and interests of the parent and the child. This strategy is going to be specific to your family. For me, I have gotten my 5-year-old into rock climbing and running. Do what works for yours.

Consider the Implications of Helicopter Parenting on Well-Being

Terri LeMoyne and Tom Buchanan of the University of Tennessee at Chattanooga explored the style of “helicopter parenting” on a sample of college students. They found that helicopter parenting can have a negative effect on children; lowering their levels of well-being and making them feel more negative about themselves. Children of helicopter parents are also more likely to take medications for anxiety and/or depression (LeMoyne & Buchanan, 2011). Ill effects of over-parenting were also shown in other studies. For instance, one led by Chris Segrin of the University of Arizona, Tucson, highlighted that helicopter parenting can lead to child having difficulty in relating to others (Segrin et al., 2014). Science shows us that although a caring and genuine relationship is essential for our children’s well-being, they (and we) will probably be happier if we give them less direction. Again, make sure your parenting style is not the culprit. When the time is right to play with your kids, let them guide you and generally only intervene for reasons of safety and security.

Don’t Take Life Too Seriously, No One Gets Out Alive Anyways

If you constantly strive to be a flawless parent, then my guess is you are probably not having much fun anyway. Having parental standards is important, but try your best not to turn this into perfectionism. There are rewards for being a flexible parent. Studies show that authoritarian parents who are high on demands and low on responsiveness tend to have children who have low self-esteem and are overly worried about making mistakes (Hibbard & Walton, 2014). Nicholas Affrunti and Janet Woodruff-Borden from the Department of Psychological and Brain Sciences at the University of Louisville also suggest that parental perfectionism and over-control can be risk factors for the development of child anxiety (Affrunti & Woodruff-Borden, 2015). So embrace your silly side.

Deploy a little healthy code-switching and become a kid yourself during play. The practice can be healthy for all involved. There is inherent fun in getting silly and laughing with someone. You both release oxytocin, which in turn creates strong bonds with each other, which in turn makes you feel good — plus a host of other benefits that contribute to the well-being of both parent and child.

Create Fun Rituals

This is one I have borrowed from my best friend Micah and his family. I am trying to get better at this one, but it the spirit of authenticity I must admit I have failed a bit here. The recognition that routine “family time” is important for family relations and well-being is well-established. Weekends play an important and beneficial role in the lives of many families in this regard — they give us more time to do things together. Rosalina Pisco Costa, a sociologist working at the University of Évora in Portugal, writes about the creation of “special time and space” and family rituals. Family rituals can center around different things (celebrations, greetings, trips) and involve the stages of anticipation, experience as well as conclusion (Costa, 2014). Costa also cites the work of Imber-Black and Roberts (1998) who suggested that “rituals give us places to be playful, to explore the meaning of our lives, and to rework and rebuild family relationship” (p.4). Fun rituals are something we can consider including in our family life to experience the emotional benefits they bring. Circling back to Micah and his family, they invested in a boat knowing that the significant cost would ensure that maritime activities, such as weekly sleepovers on the new boat, would become the norm and create endearing memories for all.

I am not suggesting you go out and buy a boat. I am suggesting you make family time a habit by engaging in a family ritual the whole family enjoys.

Invest in Experience, not Things

I feel like this has been covered well recently by others (see: Buy Experiences, Not Things or The Science Behind Why You Should Spend Money on Family Holidays Instead of Toys) and is almost a cliché topic now, but it is still worth a mention. Investing in experience over things builds memories that all parties can relish. Furthermore, since you likely have some control of your family’s resources, choosing an experience over buying another toy interjects some autonomy back in your life. We know the benefits from experience last longer than the gratification derived from most tangible things. Moreover, you don’t have to succumb to the pressure of going to a child-centered destination like Disneyland for your family vacation. What is an experience that would create an enjoyable, lasting memory for all involved? If you plan your vacations accordingly, you can mitigate the ill-conceived adage: children make a family, but destroy the marriage. Pick a location where the tips from 1-5 (above) are baked in. For instance, you could choose an all-inclusive resort that has a kid’s club so there are opportunities for family fun, as well as intimate time with your partner while your kid is at play. Fun for all!

The Days Are Long, But The Years Are Short

If you are lucky enough to find unwavering fun in being a parent … I am happy to hear that unicorns exist … something for me to strive for. For the rest of us, we tell our friends, “Don’t worry, it gets better,” because it can … especially if we are able to parent mindfully. Life is about moments, and as parents we have committed to a lot of those moments being with our kids. Either by choice or lack of family planning, these moments are not just ours anymore; however, we still hold a few cards and we can influence our environment and our family time to maximize our ability to have fun and be happy (along with our kids).

Parenthood can easily become a shitshow at times, but we have more control over that than we think. The days are long, but the years are short — we might as well stack the deck in our favor, so in our final days we have a lifetime of fun memories and we can relish in a family life lived happily.

I live on the island of Alameda, California — here on the island there is a place that has begun to wear on me. It’s called Pump It Up, a favorite among local parents for children’s birthday parties, and there is nothing inherently bad about this place. I suppose selfishly I do not like it because I have not connected with many people in the parent circle of my kids … and this type of event is solely for our kids. It is boring and no longer novel (because of the amount of times we’ve all been there), and I find myself questioning my existence every time it is my turn on the rotation to take one (or both) of my children to one of these parties. (I wonder if my parents had a similar disdain for Chuck E. Cheese?)

Since I am a psychology geek, I do take solace that these parties provide fertile ground to ponder the value of friendships. One, because it is a fascinating place to watch the storming, norming, forming marvels of childhood. Two, since my children are preoccupied, the experience gives me the space to mindfully explore my own loneliness and my lack of sensibilities in building rapport with strangers (i.e. the other care givers that somehow pulled the short straw that day). The recent resurgence and virality of Harvard’s Grant and Glueck study (which, in part, indicates that men with happier childhoods likely have stronger relationships in old age) has had me recently pondering these subjects more deeply than usual.

Please do not get me wrong. It’s not that I don’t want to be friends with the parents of my kid’s friends. On the contrary, science backs up the notion that good friends can be one of life’s greatest gifts. Alas, I suspect at least half of you reading this are better at building and preserving close relationships than me. If one’s ability to acquire friends has a standard distribution, I am for certain on the losing end of the bell curve. I have always been an odd ball. My psyche is staffed by Tim Burton characters — witty, funny, yet flawed and weird looking. These characters don’t stay in the cage long during cocktail conversations, and they get apathetic easily — they’re looking for wit and humor on the other end, not another conversation about child rearing and my day job. I do have a script for the latter, but it is long and boring. Once this script is triggered, I have literally had parents simply walk away as I meekly fade out my dialogue, embarrassed that I have killed yet another one.

At the risk of doing that to you here, let me get on with it. I know I have to try harder. In her book Friendships Don’t Just Happen, Shasta Nelson points out that making, keeping and changing friends is perhaps one of our most important skills. In reality, I think there are a lot of people like me that feel “developing” friends can be a messy proposition. I, for one, remember reading the book How to Win Friends and Influence People by Dale Carnegie and then putting it down feeling almost as dirty as I did when completing The 48 Laws of Power by Robert Greene. Authenticity is a personal value of mine, so I don’t want to boil down making friends to a “system” — so at these parties I have stopped trying and instead navel gaze while watching the kids play…

Parents have a significant influence on who our kids will be friends with

Different aspects of a child’s personality can be assessed simply by observation (e.g. self-control, self-esteem, mood, relationships with others and self-reliance). I personally look for self-reliance in my kids since it correlates with success. Self-reliance has been defined by Diana Baumrind, a researcher of human development from the University of California, Berkeley, as ‘the ability of the child to handle his[/her] affairs in an independent fashion relative to other children his [or her] age.’ Things to foster in kids in this regard are: ease of separation from you, willingness to be alone at times, leadership interest and ability, as well as pleasure in learning new tasks. Research by Baumrind (1967) shows that the parenting style that resulted in well-developed self-reliance includes being firm, loving, demanding and understanding. I think my wife and I are doing the best we can here, and building this self-reliance will hopefully lead our kids to more secure friendships.

Less is known about the influence friends and peers have on our child’s development

We know as our kids move through developmental stages, they become increasingly dependent on peer relationships and peer communication. There is little doubt we also influence this. Salient connections have been found between the relationship we have with our kids when compared to their later relationships with friends, as well as with their future romantic partners (Farley & Kim-Spoon, 2014). For instance, one longitudinal study found that adolescents who were insecurely attached to their fathers were more likely to develop an insecure attachment to their best friends. Similarly, insecure attachment to mothers led to more insecure attachments to romantic partners later in life (Doyle, Lawford, & Markiewicz, 2009). Clearly, building strong bonds with our kids is important, because ultimately they get the final decision who they keep as friends.

Why does friendship matter for our kids?

How our children evolve getting along with their peers can be an important predictor of their academic success. North American studies show that children who have a better relationship with their classmates perform better in school, and peer acceptance and attachment have been linked to academic achievement (Kingery, Erdley, & Marshall, 2011). Kids with a bigger social network have more opportunities for engagement, encouragement and support. An extensive literature review by Burack and colleagues showed that children with more positive peer relations also show more prosocial behavior, self-esteem and perceived support, and are less likely to develop depression, aggression and anxiety (Burack et al., 2013). Close relationships with peers have been found to provide children with a safe base from which he or she can explore and develop (Laible, Carlo, & Raffaelli, 2000).

Why does friendship matter for us?

I am in my 40s now. Unfortunately, a simple truth is that once parenthood hits it gets more difficult to connect with others. There is a really good 2012 New York Times article by Alex Williams where he examines the topic of making friends as an adult. Williams points out to make close friends three conditions need to be fulfilled: proximity; repeated, unplanned interactions; and a setting that encourages interactions that can be confidential. Unfortunately, these conditions are often difficult to fulfill once we have a job, a partner and/or a family.

Do I work too hard to have friends?

Some authors wonder if becoming successful results in having less contact with family and friends, which could create a sense of loneliness – ‘the top is not a crowded place’ (Reinking, & Bell, 1991). However, various scientific studies contradict the notion it is lonely at the top. Those who hustle actually have reported less loneliness compared to those that work fewer hours in comparison (Bell et al., 1990), and another study from the 1990s looked at people’s position in organizational hierarchy (which was interpreted as a level of success) and their corresponding loneliness. The findings support the premise that employees working at higher levels of an organizational hierarchy are not lonelier when compared to those working at lower levels (Reinking, & Bell, 1991). This is further supported by a recent Harvard Business Review article currently making the rounds: Does Work Make You Happy? Evidence from the World Happiness Report.

Conclusion: True friendships are invaluable

The final act of a Pump It Up party is the cutting of the cake. It is at this point I generally find myself pinching my leg until it is time to leave. The uneasiness reminds me I miss adult parties with my own friends; but the truth is this is self-inflicted misery — merely a by-product of not prioritizing pre-existing relationships accordingly. I can do better. Kid’s parties, whether I like them or not, are also important for developing good social habits in my children. The influence I yield about viewpoints on friendship influences my children’s behaviors and characteristics. It will develop how they relate to their peers. Science tells me children with more secure attachments, develop more secure friendships. My children’s ability to connect with their peers will likely influence their academic achievement since being accepted by your peers is correlated with academic success. I also know that the simple truth I am mindful of all of this means no matter how bad I fuck up (and I will), they’ll probably turn out okay.

As we grow older, for many (myself included) it is simply difficult to meet new people who become close friends, so we revere early relationships which provide us the positive support and encouragement we need to continue to develop and grow. Those that get my newsletter know my little brother recently passed away. If it was not for the support of my best friend from college, Micah, I don’t think I would have made it. If you are familiar with Dunbar’s work, then you already know science says we can only have five close friends anyway; if true, I’m truly a lucky man Micah is one of them.

We need the bonds of friendship to flourish. The presumption that people who work more become detached from their family and friends has not been supported by science, so this cannot be used as an excuse. We can, however, do a better job staying connected to old friends no matter what the distance and circumstances. As the findings from the Grant and Glueck study suggest, it might be one of the best things we can do for our well-being.

So … maybe it’s time to get the gang back together, tap a keg, and rent a bounce house suitable for adults? We won’t let the kids in, they can sit outside, bored; let them talk about how silly and annoying we are for a change.

Last quarter I mentioned I wanted to start exploring fun and play more deeply. Certainly I have mastered the art of work, but somehow I have found fun increasingly elusive. Being the nerd I am, simply observing the benefits of fun from my daughter’s delightful play was not enough. I had to dig into the science. As such, I wrote the post: Why You Need More Fun in Your Life, According to Science. It was a self-serving assignment — something to work on, because heaven forbid I spend the time having more fun. I discovered I am not alone in experiencing the elusiveness of fun, because it was my first post to truly go viral with 100s of likes and shares. Since then I have been digging into fun, and … well … it’s been fun. There is a lot to unpack: fun; play; happiness; autonomy; flow — science reveals to us these are not tangible puzzle pieces that each have their respective place. Instead, for each of us, they are unique parts of a complex quilt that when aptly patched together making our lives more fulfilling and helping us build resilience against the bad stuff.

The truth is, sometimes life is not fun. I was thrown another curve-ball recently. I was diagnosed with osteoarthritis and had to have corrective hip surgery. I was told until science catches up with my condition, I am no longer a runner. Even just typing that out — I am no longer a runner — creates internal cognitive dissonance (i.e. it’s sucky). I can choose to let this identity change get me down, or I can adjust to new forms of fun and play. To know if change is beneficial, it is important to understand how to make personal assessments and gauge whether new adaptations are working for you (or not). This quarter, I reached out to two thought leaders in the space of self-evaluation: one a best-selling author, the other one of the leading psychological researchers at Harvard.

Business, Innovation and Entrepreneurship: The interview this quarter is with Cathy Presland about tracking progress. Cathy is considered an expert on leadership, drawing her knowledge from over 20 years of experience working with governments and international organizations. She is also an international bestseller and runs the World-Changers’ Circle program from her office in the UK. My interview with Cathy Presland is available here.

Health and Wellness: This quarter’s interview is with Matthew Nock, Ph.D., about assessing an intervention using only a single individual (i.e. n=1, self-experimentation). Matthew is a leading expert in single-case experimental design. He received the MacArthur “Genius” Award in 2011 and is currently a psychology professor at Harvard University, where he also runs the Nock Lab. My interview with Dr. Matthew Nock is available here.

Life Experience: This quarter, I traveled to Houston for Super Bowl LI. I also had hip surgery, which I alluded to earlier. Both significant life experiences — however, Houston was notably more fun than surgery, so it gets the photographic evidence.

Super Bowl LI | Houston, Texas

Contribution: This quarter, I made donations to Tour de Cure again, as well as Little Kids Rock. More importantly, I made time to share the gift of contribution with my daughter. Sloane and I spend an afternoon at Crab Cove in Alameda, California, helping to clean up the beach there with a host of other local volunteers.

Crab Cove | Alameda, California

Lastly, this quarter Charlie Hoehn, author of the book “Play It Away,” found my website. When we were able to connect, it made my day. I am a fan of Charlie’s work so I wanted to finish this newsletter paying it forward and plugging a new book he is working on: Play for a Living. I am hopeful I will be able to coax him into an interview sometime in the future.

Matthew Nock, Ph.D. is one of the leading experts on n-of-1 experiments and single-case experimental designs. Matthew became a MacArthur Fellow in 2011 receiving the MacArthur “Genius” Award. He studied at Yale and now is a professor at Harvard where he also runs the Nock Lab. In addition to his research interests, Dr. Nock has been counsel to the World Health Organization’s World Mental Health Survey Initiative, the National Institutes of Health, the American Psychological Association, as well as other prestigious health organizations.

1) Assuming I have captured the basic methods of single-case experimental design (SCED):

Identification of specific target behavior

Continuous and valid measurements

A baseline period (data is gathered before the intervention is applied)

Stability of the specific target behavior (target behavior changes only when the intervention is applied)

Systematic application of intervention

What are the considerations, risks and advantages for someone partaking in self-experimentation — someone who wants to use these methods to help determine the efficacy of a new habit or practice (e.g. determining the effect of meditation on mood)?

These are the basic methods, but it is important to note there are some variations in how you would apply different types of single-case experiments. Once the intervention is applied, then something else is going to happen next, right? For instance, there is “AB-AB design” also known as “withdrawal design.” In this application, you apply the intervention, you then remove the intervention and examine whether the behavior/condition reverts to the baseline level. You then reapply the intervention — so the A state stays as baseline, the B state stays as an intervention — so you do AB, AB and measure the change.

For instance, if you wanted to see if a reward program for not smoking cigarettes worked for you. You start with cigarette smoking as your baseline. Let’s say you smoke two packs a day. Now you apply the reward (intervention). After the reward you now smoke half a pack a day. You then remove the reward (intervention), going back to baseline (smoking without a reward for not smoking), and you see if you go back to two packs a day. You then reapply the intervention (in this case the reward) in an attempt to determine that it is when, and only when, the intervention is applied that your behavior changes. This method helps you rule out alternative explanations. For instance, in this hypothetical example you rule out that you stopped smoking because of some historical event, or your wife told you she’s going to leave you if you don’t stop smoking at the exact time you started the intervention.

What you are trying to accomplish is identifying the result from the experiment is from the intervention and nothing else. You can do an AB-AB design as described, or, if you have access to other participants, you can do a multiple baseline design. In this example, the first person, they would have a one-week baseline and then you apply the intervention; the second person would have a two-week baseline, then you apply the intervention; for the third person, a three-week baseline then you apply the intervention. Again, if you can show when, and only when, you apply the intervention something has changed, you have evidence that your intervention causes change in people.

A single person can also use a multiple-baseline approach across behaviors. For instance, I am trying to change my smoking and drinking and eating. I could apply the intervention to my smoking, then apply it to my eating, and then apply it to my drinking. If I see that when, and only when, I apply the intervention my target behavior changes, it provides evidence that my intervention is effective. You can apply the multiple baseline approach across people or across behaviors.

If someone is self-experimenting, they will want to do their best to collect their own data objectively. Using these methods on yourself, you run the risk of tricking yourself into seeing something that is not there or failing to see something that is there. When it is a clinician or a researcher observing you, they are going to be, with their own objective eyes, carefully measuring some behavior of interest. If you are not carefully measuring objectively what it is you want to change, again, you might see change that is not there or fail to see change that is there. It is important to do your best to objectively measure.

The benefit of this approach is you are the one following the data. You have a real-world answer to whether or not your intervention is working. It can be just a little bit of extra work to do something like this, to quantitatively, objectively measure your own behavior. However, in my opinion, that is also a benefit: knowing what’s effective; knowing what can change your behavior at a fairly minimal cost.

2) For many, “lifestyle design” is about optimization. For example, using meditation as the hypothetical again, it appears that many find benefit from only minimal exposure (Creswell, Pacilio, Lindsay, & Brown, 2014), but one could posit the effective duration is unique to the individual. Since interventions generally come with an opportunity cost, reducing this cost has a benefit. What are some good strategies for expediting the determination of the minimum effective dose (MED) of any given intervention?

In my mind, there are two philosophies about this. One is start small, and measure carefully the effects of the small dose/intervention, and then increase, increase, increase, until you see maximum benefit(s) and then you might know how much is needed. The other is the opposite; start with the maximum dose and then work down from there. Each has pros and cons, right? It certainly depends on what it is you’re using as an intervention. If there is any toxicity associated with the intervention — drugs are an obvious example — if there are toxic side effects to an experimental drug, you would want to start very small and work up to see what is the needed dose to cause change. The benefit here is you are not exposing the subject to toxicity; the downside is it could take longer for an effect and the person could be engaging their harmful behavior, or suffer from disease, for longer intervals of time than giving them more from the onset. On the flip side, if you start with the maximum dose, you generally will know right away whether it has an effect and then you can work down from the initial amount. The downside is you are now exposing the subject to any toxic side effects from potential overdose. If you are certain the intervention does not have any toxicity and/or limited risk, I think the best thing to do is start with the maximum amount and then work down from there to see how much is needed to maintain the effect.

3) Technology is making the recording and analysis of self-experimentation more accessible. There are an abundance of consumer and condition-specific wearables for collecting data, ecological momentary assessment (EMA) protocols are accessible to anyone with a smartphone, the statistical package R is free to use — enabling anyone willing to take on the learning curve the ability to crunch their own numbers. What technology and innovation excites you in this area? And, is there anything that is currently helping democratize one’s ability to run these types of experiments?

There are a lot of tools at the ready now with smartphones and other wearable devices, so people can collect and analyze their own data quite easily. The big bridge is people often are not going to want to learn something like an open-source statistical program. Learning a statistical program like R, even though it is free, is not a minor endeavor. People want ready-made solutions to problems, so they want an app that is turnkey and ready to go. Technology that is going to monitor their behavior, apply the intervention, whatever it is … to the extent that we can create applications that bridge that gap for people, that are easy to use, people will likely use them.

So yes, there is some great open-source stuff out there, but getting someone to figure out how to collect their own data effectively, then create and apply their own intervention, learn statistics (even if it is free to do), analyze their data; wow, this basically requires an intervention in and of itself to get someone to do that.

The thing that excites me most right now is using wearable devices and smartphones to collect data about people and apply interventions that are beyond their own awareness. There are apps available now that allow us to collect data from people’s smartphones passively. We can monitor their GPS, we can monitor their sleep, we can monitor their activity level, who they’re calling, who they’re texting, who’s calling them, who’s texting them, and we may pick up information that can predict future behavior that people are not aware of themselves.

For instance, if a person’s activity level is decreasing, they have outgoing calls and texts and none are getting returned, and their sleep becomes more irregular, we might predict this person is becoming more depressed. So a condition a person may not even realize they have themselves — we can use information from their phone to help identify potential problems and deploy an intervention remotely before the condition can cause any negative effects. We now have e-interventions, smartphone interventions, where people can engage in a little quick, game-like app that they can play to try and change their behavior. The old model of going to a doctor, the doctor does an assessment and tells me I have a problem, then gives me some kind of treatment — this model is changing. We can now go out and find people who are in need of help before they know they need it, and send interventions out to them that they can use and apply themselves. We can deploy this on demand, 24 hours a day, 7 days a week, whenever it works for the individual.

4) You are a Harvard psychologist. You are also one of the leading experts on destructive behavior. There seems to be a resurgence of William James’ ideas lately, specifically that if we master our free will and make ourselves 100 percent accountable for our actions, this process will increase our chance of positive outcomes. Do you believe in the validity of this assertion? And, given your expertise working with people where this process might pose difficulties, what are some strategies to assist one to increase their ability to be accountable in this area?

My department resides in a building called William James Hall, so the spirit of William James is still present. The idea of holding ourselves 100 percent accountable, as it pertains to the way I am interpreting your question, comes down to the rewards and the costs of a behavior. If we want to change our own behavior, we need to accurately understand to what extent the behavior in which we are engaging is rewarding or beneficial. We also want to accurately understand what the costs involved are. We have to seriously evaluate both the rewards and cost. For instance, if I am smoking cigarettes, I probably feel good after I smoke. In this case, what are the rewards and costs of smoking? It means realizing there are benefits, but there are also significant costs engaging in the behavior. I need to weigh both, but to do so I need to accurately consider present and future elements of the behavior.

So for me, holding ourselves accountable means realistically realizing the cost and benefits of our behavior and weighing those carefully. If the costs are going to ultimately outweigh the benefits, then I think we have a chance of decreasing risky behavior. If the benefits are perceived as outweighing the costs, it is much tougher to change someone’s behavior. For instance, take a self-destructive behavior like cutting oneself or burning oneself, why would someone do that? It turns out that cutting yourself or burning yourself, for many people, removes aversive thoughts and feelings. This behavior has a benefit for them. For these people, the reward of removing these thoughts appear to outweigh the costs of seeing tissue damage, and so they engage in the behavior. Getting people to stop engaging in this behavior is a lot about figuring out other ways to get the existing benefit for alternative behaviors that do not carry such a heavy cost.

I think the same is true with smoking, drinking and overeating — as well as other problematic behaviors. These behaviors have associated rewards, but they also can come with significant costs. To make good choices, we need people to understand and appropriately weight the costs and the benefits. An important part of the process of behavior chance is to figure out ways to have people find similar benefits that do not carry the same costs of the behavior one hopes to change. The challenge is how to get yourself to feel good and/or distract yourself from aversive psychological states, without doing harm to your mind and/or body. If the spirit of your question is, “How do we increase our chance of positive outcomes?” then you can look at it as benefit-cost=outcome. To do this, you need accurate information about the behavior’s costs so you are not discounting and/or ignoring these. Then look at the behavior’s benefits and find suitable alternatives that offer comparable benefits without the associated costs of the behavior you are trying to change.

5) A young student has walked into your office and proclaimed they want to become the leading expert on self-experimentation. What are three rabbit holes you suggest they explore (i.e. ideas, concepts, models)?

Three rabbit holes they should explore …

1) Read up on the decades of research that people have done on single-case experiments and N of 1 designs. There are a lot of well-worked out-methods and approaches to measuring behavior and carefully, systematically applying an intervention to change behavior, as well as observing the effect of the intervention. When you really understand these validated methods, then you are aware when you are truly doing experimentation. We have existing study designs where one can carefully observe the outcome of self-experimentation in an empirical manner — opposed to reinventing the wheel, there are decades of existing work that one can build on, so mastering the current available literature in this area is a big one.

2) Mastering new technology. As we discussed earlier, there have been significant, recent advances in technology available to people interested in experimentation in the form of smartphones, wearable devices, the Internet and free access to educational information. We have easy access to data at our fingertips now. Through technology we can easily measure our real-world behaviors. Mastering new technology will allow a person to tap into a huge new source of objective data on our behavior.

3) Once you master experimental design and you master the latest technology, the last rabbit hole I’d suggest is how to engage and measurement your experiments. You need to figure out how you can use advances in technology to develop new interventions based on what we already know works. Questions like, “Are we effectively using carrots and/or sticks? Are there ways that we can use computers, the Internet, smartphones, wearable devices, to try and apply new interventions?” The new frontier regarding behavior change is to master the way that we try and modify people’s behavior (or modify our own behavior?). With the right creativity — coupled with an existing mastery of the first and second rabbit holes — there is a lot that can be done using the new tools that we have at our disposal. We now have the ability to apply personalized behavior-change interventions, in real-time, at scale.

There is a downside to this third rabbit hole, too, though, especially if you are building tools that help others self-experiment. There are now thousands of thousands of apps out there that are purported to improve health and well-being. However, by my reading, there is very little data to support that most of these apps are actually effective in any meaningful way. Moreover, there is little evidence to suggest that most of these apps will actually change anyone’s behavior. Worse, there is a financial incentive to create apps and to market to people, “This app will make you healthier and happier.” In my opinion, there is not a good public understanding of how to evaluate scientific evidence. That makes it difficult for most to evaluate claims about effective treatment and/or interventions. It’s the Wild, Wild West out there.

Before scientific medicine, people just created their own methods. They could sell snake oil. They could put anything in a bag or box and sell it to us as effective. Some were and some weren’t, and many times the ones that were effective, weren’t effective for the reasons that people thought. Luckily, now we have a much better infrastructure where, if you are going to sell some kind of FDA-approved medication, you have to know what is in it and show that it is effective in randomized clinical trials. It’s on you, you’ve got to have experimental data. I think of the app world as similar to the Wild, Wild West. People are now deploying things that they say are treatments and there is not a good, systematic infrastructure in place to know which ones are experimentally sound and which ones are not. Similar to the thoughts expressed in the previous question, there needs to be a clear benefit to making experimentally sound apps. This benefit could be a special designation, like FDA approval or FDA approval equivalent. Something that ensures it has been tested, with evidence showing that it works. If the app does not have that, then some kind of repercussion for the makers. Until we have that system in place, I think you will continue to see a market full of snake oil.

Cathy Presland, a former economist, runs the program World-Changers’ Circle that takes five action-takers on a 6-month journey of transformation. She is an expert on leadership, both personal and professional, and inspires people to look beyond themselves when they make their life and business decisions. Cathy draws her knowledge from over twenty years of experience working with governments and international organizations on different public policies, programs and regulations. Cathy is a respected motivational speaker, teacher, mentor, facilitator and an author. Her book, Write! Stop Waiting, Start Writing. A Step-by-step Guide to Turn What You Know into a Book, is an international bestseller and is just one of the ways Cathy is supporting people who feel they have an idea that they want to share with the world.

1) If someone is looking to create a system to track their process towards some sort of desired change and/or personal improvement, how would you coach them through building this architecture so they can successfully develop a measuring protocol that assists them with meaningful metrics that assist with experimentation and continual improvement?

I think that at the core of any kind of monitoring is the question: is the process serving the end goal? Sometimes this is just a feeling, and sometimes, it is some kind of a quantified measuring protocol. I’m not so interested in numbers; I’m interested in where we are trying to get — How can we make the process more joyful, therefore, making it easier to get to the goal, regardless of the number? In my experience, if we put a measurement around a goal too early, the number becomes more important than the result we’re aiming for and there is no scope for creativity. We’re then quick to jump to self-criticism about not hitting some made-up target which sets off a cycle of demotivation. Measurements are especially not helpful in the early stages when we are just setting up doing something. Sometimes, you first need to do something to test your theory without having to deal with the danger of negative feedback that can come from creating your own metrics. If you want quantification, do a two-week experiment and see how you feel. You can put some measurement around it later if you feel you want to move it forward. So, very rarely would I rush into measurement from the outset.

I’ve got a client at the moment, for example, who’s applied for a number of jobs, and she’s not getting the results she wants. So, we had a conversation about what else could she be spending that time doing? It transpired that it wasn’t working for her because she wasn’t really inspired by the jobs she was applying for. This was the start of an honest conversation. I’m interested in what is going on in our minds that is creating good or bad feelings. When my client has an insight, and she realizes that she wants to be doing something differently, she should just be able to go off and do it. She doesn’t necessarily need to monitor things. Too much measurement can strain your results I think. It may be just about how honest we’re being with ourselves about the things we are doing, whether the things that we’re doing are going to give us the results that we want.

2) When someone is faced with assessing a life change where the present state/status quo is comfortable and satisfactory, and the future state being evaluated is high risk but high reward (i.e. the change requires deviating from an existing desirable state) — what effective strategies, processes and/or frameworks have you found useful for individuals to use to increase the likelihood of making a successful decision?

Life is never a low-risk, high-risk situation in my experience. The future is always unknown. None of us literally knows what we’re going to be hit with personally, professionally, so to me, that is never what it’s about. The actual situation is less important. The only thing that really matters is how we’re thinking about the current situation and what moves we’re making.

I don’t have a framework I could prescribe. What I do have is a philosophy. I do think there is a place that we can come from, because, as individuals, we’re so tiny and meaningless. And, the less consideration I give to me, the more contribution I’ve got to make — to one person, to my children, to my family. I try to have a discussion around what is important to the person in that coaching conversation. What is it that they feel in this moment is the right thing for them to do? It’s about removing your personality and your ego as much as possible, so you can analyze your decision in terms of these questions:

Am I doing this because I think I’m going to be happier in some way, which is a red flag because our feelings don’t come from our circumstances?

What is the greater good in this situation? What feels ‘right’?

And, at the same time, I also think that the right thing is something that we create in our imaginations. So, I don’t see that as a fixed thing; I see that as a drive, a movement, an action at this point in time.

3)In contrast to the previous question, it is my opinion (given the immense amount of advice currently available about improving performance) that people often get stuck consumed by integrating seemingly endless methods (e.g. life hacks, productivity approaches, etc.) that either act as distractions and/or worse — impede progress towards what really is desired. What is your opinion on this assertion and do you have a process with your clients on making strategic decisions on what not to do? Lastly, in this regard are there commonalities that lend themselves to general advice that would benefit most people about what not to do?

I certainly see life hacks as distractions. And, I think that they can impede progress when people give them an importance that they don’t deserve. A lot of life hacks, especially in the personal development world, are designed to try to create some kind of space. Meditation, or anything in that zone, is designed to try to create some space so we can get some clarity. But, the process often becomes an end in itself, like, “I’ve got to meditate”. And we forget that we have access to that space in our heads at any moment. Some people have found life hacks helpful, but the reality is that we don’t need them.

We’re very good at making up things that we think we want and then trying to think our way there. We go into this cycle of over-thinking, whereas, if we actually just gave ourselves mental space, we’d probably already know what it is that we want to do. But, we just don’t accept it, or we don’t see it, or we don’t think this is it; we kind of don’t know what it looks like. So we spend a lot of time chasing things that we don’t really want to do, or things that other people have, which are completely pointless wastes of time.

People that have enough perspective to know that something is not real or is going to pass, do better in life. We need to distinguish between what’s real and what isn’t. Generally, there are some things that look more real than others to people. Money is a typical example here. Many of us think money will create a feeling of security — but the security comes from within us, not from something external. Similarly, doing something because it’s going to lead to something else — taking an action or a path “so that…” or because there is an ulterior motive beyond the immediate is generally a wrong decision, too, and you are fooling yourselves if you are taking intermediate steps to something. If there’s something that you want to create, there’s always a more direct way to do it. For instance, “If I make lots of money, then I can create a foundation to do good in the world.” It’s like, why not just do good in the world now?

The other kind of big general thing that I will comment on is that people seem to think there is somewhere to get to. However, there’s no forward motion. It’s a real trap to believe that there is forward motion because then we’re always trying to get somewhere that we’re never going to get to. It’s just motion, in all sorts of directions and, often, that can be hard for people to conceptualize because we are so conditioned that there is a timeline in life, a journey from A to B. That’s a myth, there is only where we are now.

4) What are good indicators that it might be time to give up on a big idea/plan/goal? Using my own goal as the example, the Boston Marathon has always been a stretch goal, albeit an achievable pursuit — until recently where I was advised never to run long distances again. The Web is cluttered with advice to never give up on your dream, but science suggests this “inspirational” messaging has had some significant negative consequences. What is a suitable gauge and process for determining a goal has realistically fallen out of reach?

For me, this comes down to removing the ego from the decisions that we make. It is about heading in a certain direction and making the most of the opportunities we have rather than regretting those that are not open to us right now. It’s kind of direction versus outcome. And what is important for me is the direction and coming from a higher self … it can be difficult for us to create that separation between what we feel and what we actually decide to do. So, the higher the perspective we get on this, the easier it is to take those clear decisions. That’s where I would work with somebody. We feel what we feel; it’s not for me to tell somebody that what they’re feeling isn’t valid, because that’s what’s coming up for them. But, I will work with them in a way to show them that this isn’t meaningful in the way that they think it might be.

When a big goal falls out of reach, it doesn’t take away from you that direction that you’re heading in. For you, for example, it’s not in the cards to do the Boston Marathon anymore. Or, maybe it is. Or, maybe you can explore something else and get another route for experimentation and/or exploration. But, if you stay attached to the Boston Marathon, you’re going to lose the creativity to try out lots of different things on route to getting there. The reality is that we have very little control over what happens. We don’t know what’s around the corner; we don’t know who we’re going to meet. And, the more open and positive we are to the possibilities that are in front of us, the more fantastic things happen.

5) You run a program called World-Changers Circle. Although daring big might not be for everyone, what are some of the undervalued intangible rewards you have witnessed from those that succeed at big things?

I think that it is human nature to want to do something that goes beyond ourselves. People come to me because they want to do something meaningful, and this doesn’t have to be grandiose. Amazing things can happen when we get our egos out of the way, and these things happen faster than we expect when we do this too. You take bigger actions and make bigger asks when you’re not coming from a place of ego. There are a lot of benefits from taking a different perspective and looking differently at the world: you get calmer, have better relationships. You realize that it is actually more about how you’re looking at things rather than anything that other people have done. You realize that the world is driven internally more than externally.